=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386943546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANNA BERNICE BROCCHINI FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2011
-----------------------------------------------------
Last Update Date | 09/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1262 E NORTH ST
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-4962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-599-3860
-----------------------------------------------------
Fax | 209-599-9662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27011 S AUSTIN RD
-----------------------------------------------------
City | RIPON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95366-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-599-3860
-----------------------------------------------------
Fax | 209-599-9662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 20754
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 751355
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------